- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,246.25 / $2,246.25 / $2,807.81
| Professional | | $2,246.25 | $2,246.25 | $2,807.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,943.50 / $2,943.50 / $2,943.50
| Facility | | $2,943.50 | $2,943.50 | $2,943.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,105.00 / $7,105.00 / $7,105.00
| Professional | | $7,105.00 | $7,105.00 | $7,105.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,436.00 / $3,712.36 / $4,079.43
| Facility | | $2,436.00 | $3,712.36 | $4,079.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,712.36 / $5,176.50 / $5,298.30
| Professional | | $3,712.36 | $5,176.50 | $5,298.30 |